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   Table of Contents - Current issue
Coverpage
March-April 2021
Volume 69 | Issue 2
Page Nos. 241-541

Online since Saturday, April 24, 2021

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NI FEATURE: THE FIRST IMPRESSION  

Vertebral Artery Course Variations and Implications in Craniovertebral Junction Surgeries p. 241
Sandeep Kandregula, Bharat Guthikonda
DOI:10.4103/0028-3886.314593  PMID:33904430
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EDITORIAL Top

Basal Cisternostomy: Hype or Hope? p. 243
P Sarat Chandra
DOI:10.4103/0028-3886.314592  PMID:33904431
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REVIEW ARTICLES Top

eNeuroIntensive Care in India: The Need of the Hour Highly accessed article p. 245
Sai P Haranath, Krishnan Ganapathy, Subba R Kesavarapu, Swarna D Kuragayala
DOI:10.4103/0028-3886.314591  PMID:33904432
Background: As ICU consultants in smaller hospitals may not be familiar with neurocritical care and with current travel restrictions due to the COVID-19 pandemic, one needs to relook at how neurocritical care can be provided. Objective: This article reviews the authors' experience of providing remote neurointensive care, from a non-specialist ICU over a 16-month period. Material and Methods: 61 neuro consultations were provided for 56 patients admitted in remote ICU's, including five repeat consultations. Most teleconsultations were from three rural hospitals. The central command center has monitored remote patients with neurological conditions, in 23 ICUs. Results and Conclusions: Providing real-time virtual neuro intensive advice to ICU's in smaller cities even without dedicated neuro-intensive units is feasible in India. eNeuroIntensive care is particularly necessary in the current “New Normal” era.
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Chronic Neurological Disorders: Genetic and Epigenetic Markers for Monitoring of Pharmacotherapy p. 252
Sudhir Chandra Sarangi, Pranav Sopory, KH Reeta
DOI:10.4103/0028-3886.314522  PMID:33904433
Introduction: Chronic neurological diseases are a major cause of mortality and morbidity in the world. With increasing life expectancy in the developing world, the incidence and prevalence of these diseases are predicted to rise even further. This has also contributed to an increase in disability-adjusted life years (DALYs) for noncommunicable diseases. Treatment for such diseases also poses a challenge with multiple genetic and epigenetic factors leading to a varied outcome. Personalization of treatment is one way that treatment outcome/prognosis of disease can be improved, and pharmacogenomics plays a significant role in this context. Methodology: This article reviewed the evidence pertaining to the association of genetic and epigenetic markers with major neurological disorders like multiple sclerosis (MS), Alzheimer's disease (AD), and Parkinson's disease (PD), which are a major source of burden among neurological disorders. Types of studies included are peer-reviewed original research articles from the PubMed database (1999–2018). Results: This study compiled data regarding specific genetic and epigenetic markers with a significant correlation between the clinical diagnosis of the disease and prognosis of therapy from 65 studies. In a single platform, this review highlights the clues to some vital questions, such as why interferon beta (IFN-β) therapy fails to improve symptoms in all MS patients? why cholinesterase inhibitors fail to improve cognitive impairment in a subset of people suffering from AD? or why some individuals on levodopa (L-DOPA) for PD suffer from side-effects ranging from dyskinesia to hallucination while others do not? Conclusion: This article summarizes the genetic and epigenetic factors that may either require monitoring or help in deciding future pharmacotherapy in a patient suffering from MS, AD, and PD. As the health care system develops and reaches newer heights, we expect more and more of these biomarkers to be used as pharmacotherapeutic outcome indicators.
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Neuroimaging Patterns in Patients with COVID-19-Associated Neurological Complications: A Review Highly accessed article p. 260
Ravindra K Garg, Vimal K Paliwal, Hardeep S Malhotra, Praveen K Sharma
DOI:10.4103/0028-3886.314531  PMID:33904434
Background: A variety of neuroimaging abnormalities in COVID-19 have been described. Objectives: In this article, we reviewed the varied neuroimaging patterns in patients with COVID-19-associated neurological complications. Methods: We searched PubMed, Google Scholar, Scopus and preprint databases (medRxiv and bioRxiv). The search terms we used were “COVID -19 and encephalitis, encephalopathy, neuroimaging or neuroradiology” and “SARS-CoV-2 and encephalitis, encephalopathy, neuroimaging or neuroradiology”. Results: Neuroimaging abnormalities are common in old age and patients with comorbidities. Neuroimaging abnormalities are largely vascular in origin. COVID-19-associated coagulopathy results in large vessel occlusion and cerebral venous thrombosis. COVID-19-associated intracerebral hemorrhage resembles anticoagulant associated intracerebral hemorrhage. On neuroimaging, hypoxic-ischemic damage along with hyperimmune reaction against the SARS-COV-2 virus manifests as small vessel disease. Small vessel disease appears as diffuse leukoencephalopathy and widespread microbleeds, and subcortical white matter hyperintensities. Occasionally, gray matter hyperintensity, similar to those observed seen in autoimmune encephalitis, has been noted. In many cases, white matter lesions similar to that in acute disseminated encephalomyelitis have been described. Acute disseminated encephalomyelitis in COVID-19 seems to be a parainfectious event and autoimmune in origin. Many cases of acute necrotizing encephalitis resulting in extensive damage to thalamus and brain stem have been described; cytokine storm has been considered a pathogenic mechanism behind this. None of the neuroimaging abnormalities can provide a clue to the possible pathogenic mechanism. Conclusions: Periventricular white-matter MR hyperintensity, microbleeds, arterial and venous infarcts, and hemorrhages are apparently distinctive neuroimaging abnormalities in patients with COVID-19.
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Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management Highly accessed article p. 272
Priyanka Tater, Sanjay Pandey
DOI:10.4103/0028-3886.314574  PMID:33904435
Involuntary movements develop after 1–4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.
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Brivaracetam: How Well Does It Fare as an Anti-Epileptic? A Review p. 284
Madhuri Khilari, Pradeep P Nair, Brajesh Kumar Jha
DOI:10.4103/0028-3886.314584  PMID:33904436
Objectives: Epilepsy is a common neurological ailment contributing to significant disability. About one-third of all epilepsy patients would be refractory to two or more medications. Brivaracetam (BRV) is one of the newer anti-seizure medications on which extensive data is available, but its efficacy as an early add-on agent (first/second adjuvant) is unclear. The principal objective of this review is to assess the efficacy of BRV as an early add-on agent in refractory Focal Onset Seizures (FOS) and its pharmacology and usage in various clinical situations associated with seizures. Methods: We searched two databases, Medline and Cochrane Central, for papers on BRV and FOS, and selected six studies with randomized parallel control design to extract the data for a meta-analysis. We also did a comprehensive review of the available literature on its pharmacology and usage in various clinical scenarios associated with seizures. Results: For the meta-analysis, we extracted 145 articles; six studies fulfilled the selection criteria that gave us data on 1938 patients who received Brivaracetam as an early add-on agent in FOS. The Risk Ratio (RR) (95% CI) for 50% responders across the trials was 1.88 (1.55–2.29). Similarly, the overall RR (95% CI) was 5.82 (2.15–15.70) for seizure freedom. Conclusion: Our analysis provides moderate evidence for Brivaracetam as an effective agent as an early adjuvant in FOS. Its efficacy for several other indications needs further clinical trials and evaluation.
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A Systematic Review and Meta-analysis of Prevalence of Epilepsy, Dementia, Headache, and Parkinson Disease in India Highly accessed article p. 294
Vikas Dhiman, Geetha R Menon, Supreet Kaur, Amar Mishra, Denny John, Mendu Vardhan Rao Vishnu, Rajnarayan R Tiwari, Rupinder Singh Dhaliwal
DOI:10.4103/0028-3886.314588  PMID:33904437
Background: There are wide variations reported in the prevalence rates of common neurological disorders in India leading to huge treatment gap. There is no comprehensive systematic review reporting prevalence of common neurological conditions affecting Indians which is essential for developing and aligning health services to meet patient care. Objectives: The aim of this study was to perform a systematic review and meta-analysis of prevalence of epilepsy, dementia, headache, and Parkinson's disease (PD) in India from 1980 to 2019. Methods and Materials: We performed a bibliographic systematic search in PubMed and Google Scholar along with manual search for peer-reviewed cross-sectional studies and community-based surveys reporting prevalence of epilepsy, dementia, headache, and PD in India from January 1980 to July 2019. Meta-analysis was performed adopting a random-effects model using “Metafor” package in R. Results: The systematic review and meta-analysis included 50 studies [epilepsy (n = 22), dementia (n = 19), headache (n = 6), and PD (n = 3)] including a total of 179,1541 participants of which 5,890 were diagnosed with epilepsy, 1,843 with dementia, 914 with headache, and 121 were diagnosed with PD. The pooled prevalence of epilepsy was 4.7 per 1,000 population (95% CI: 3.8–5.6) with high heterogeneity (P < 0.01, I2 = 98%). The prevalence of dementia was found to be 33.7 per 1,000 population (95% CI: 19.4–49.8) (P = 0, I2 = 100%). The pooled prevalence of headache and PD were found to be 438.8 per 1,000 population (95% CI: 287.6–602.3) (P < 0.0001, I2 = 97.99%), and 0.8 per 1,000 population (95%CI: 0.4–1.3) (P < 0.01, I2 = 95%), respectively. Conclusions: The findings could be used for appropriate policy measures and targeted treatments for addressing these conditions.
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Prevalence of Major Mental and Neurological Disorders in India p. 302
Kanwaljeet Garg
DOI:10.4103/0028-3886.314556  PMID:33904438
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VIDEO SECTION: STEP BY STEP: OPERATIVE NUANCES Top

Removal of Perirolandic Cavernoma with Direct Cortical Stimulation and Neuronavigation with DTI p. 304
Ujwal Yeole, Dhaval Gohil, Dhaval Shukla, Suparna Bhardawaj
DOI:10.4103/0028-3886.314528  PMID:33904439
Background and Introduction: Intraoperative neuromonitoring for eloquent cortical lesions is irreplaceable in present-day neurosurgery. Objective: We report a novel technique of combining awake craniotomy with direct cortical stimulation of the motor cortex using the NIM© nerve monitoring system. Technique: A 17-year-old boy presenting with focal motor seizures, diagnosed with left perirolandinc cavernoma, underwent awake craniotomy and complete excision under direct cortical stimulation with NIM monopolar stimulator electrode to locate the motor cortex. Result: The patient developed transient weakness of handgrip during surgery, which improved by the same day evening. At 3 months follow-up, he could perform all the activities with his dominant right hand. Conclusion: Cortical stimulation using a nerve monitoring system is a useful technique in case of nonavailability of standard evoked potential monitoring system for motor cortex mapping.
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Bilateral Posterior Nasoseptal Flap – Double Breasting Technique p. 307
Rakshith Srinivasa, C Chandrakiran, Rini Luckose
DOI:10.4103/0028-3886.314538  PMID:33904440
Background and Introduction: The success of endoscopic skull base surgery is largely based on the effective repair of the skull base defect. A pedicled nasoseptal flap (NSF), described by Hadad-Bassagateguy is the workhorse of contemporary endoscopic skull base repair. We describe a modification in the technique, “double breasting technique,” using the bilateral posterior NSF for skull base repair. Objective: In this video article, we describe the technique of harvesting bilateral posterior nasal septal flaps and overlaying the flaps in a double breasting technique to cover the skull base defect. The posterior NSF can be used to cover medium to large skull base defects effectively. Surgical Technique: A 40-year-old female patient presented with headache and decreased vision for 2 months. MRI with gadolinium showed a sellar suprasellar lesion with chiasmal compression. Visual field charting showed bitemporal hemianopia. She underwent endoscopic transnasal transsphenoidal surgery (binostril approach) and complete excision of tumor. Intraoperatively, there was evidence of arachnoid breach with high flow cerebrospinal fluid (CSF) leak. Sella was repaired with fat, fascia, fibrin glue, and overlaid with the bilateral posterior NSF in a double breasting technique, as described in the video. Results: The skull base repair was successful, with no CSF leak postoperatively.
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Bone Wax as an Intra-Cavitary Fiducial for Intra-Operative Magnetic Resonance Imaging Guided Resections of Eloquent Cortex Glioma Highly accessed article p. 311
Kirit Arumalla, Harsh Deora
DOI:10.4103/0028-3886.314541  PMID:33904441
Background: The extent of resection of eloquent cortex low-grade glioma is improved by intraoperative magnetic resonance imaging (IOMRI) which is faced with challenges such as difficulty in automated registration after the MRI and prolongation of operative time. Objective: We describe an easier and foolproof method of resection using bone wax as fiducial. Surgical Procedure: A young male with right-frontal low-grade glioma anterior and superficial to the motor fibers was operated using IOMRI and awake craniotomy under neuromonitoring. Motor cortex mapping using phase reversal and continuous motor evoked potential (MEP) monitoring was used initially followed by continuous sub-cortical suction stimulation for deeper decompression until stimulation was seen. Bone wax in a triangular shape was placed at the suspicious margin and IOMRI was done. Results: The tumor residue was seen anterior and deeper to the bone wax and removed subsequently. Conclusion: The use of bone wax as a fiducial can aid in IOMRI-guided resection of eloquent cortex glioma in awake patients.
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Anomalous Vertebral Artery During Cranio Vertebral Junction Surgery Using DCER (Distraction, Compression, Extension, and Reduction): Approach. and Its Repair p. 315
P Sarat Chandra, Raj Ghonia, Simranjeet Singh, Kanwaljeet Garg
DOI:10.4103/0028-3886.314543  PMID:33904442
Introduction: Vertebral artery (VA) may run an anomalous course in congenital craniovertebral junction anomalies. Anomalous VA, though rare, is challenging to handle. An anomalous VA can get injured during exposure of craniovertebral junction, even in the experienced hands. Objective: The objective of this article was to describe the technique of repairing the VA in case of its damage during exposure in the craniovertebral junction (atlantoaxial dislocation [AAD] with basilar invagination [BI]). Procedure: The authors describe a case of VA artery injury in a case of severe BI & AAD, which was anomalous and coursing over the joints. Following the repair of injured VA, we proceeded with the surgery (distraction, compression, extension, and reduction [DCER]). Conclusion: To avoid injury, it is important to always perform a CT 3-D angiogram, perform meticulous dissection under the microscope while exposing the joints, use variable impedance bipolar to control venous bleeding and always expose the side with non-dominant VA first.
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ORIGINAL ARTICLE Top

Efficacy of Silicone Conduit in the Rat Sciatic Nerve Repair Model: Journey of a Thousand Miles p. 318
Suyash Singh, Arun Kumar Srivastava, Atul K Baranwal, Ankur Bhatnagar, Kuntal Kanti Das, Sushila Jaiswal, Sanjay Behari
DOI:10.4103/0028-3886.314576  PMID:33904443
Background: A lot of options have been tried for bridging the two ends of the injured nerves. Researchers have used decellularized nerve grafts, artificial materials and even nerve growth factors to augment functional recovery. These materials are either costly or inaccessible in developing world. Objective: The study aimed to evaluate the efficacy of the silicone conduit in a rat sciatic nerve injury model. Materials and Methods: 24 healthy Sprague–Dawley (SD) rats (250-300 grams; 8-10 weeks) were used and right sciatic nerve was exposed; transected and re-anastomosed by two different methods in 16 rats. In control group, n = 8 (Group I) the sciatic nerve was untouched; Group II (reverse nerve anastomosis, n = 8): 1-centimeter of nerve was cut and re-anastomosed by using 10-0 monofilament suture; Group III (silicone conduit, n = 8) 1-centimeter nerve segment was cut, replaced by silicone conduit and supplemented by fibrin glue]. Evaluation of nerve recovery was done functionally (pain threshold and sciatic functional index) over 3 months and histologically and electron microscopically. Results: Functional results showed a trend of clinical improvement in Group III and II but recovery was poor and never reached up to normal. Histopathological and electron microscopic results showed an incomplete axonal regeneration in Groups II and III. Psychological analyses showed that no outwards signs of stress were present and none of the rats showed paw biting and teeth chattering. Conclusion: The silicone conduit graft may be an economical and effective alternative to presently available interposition grafts, however for short segments only.
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Nerve Guidance Conduits: Journey of a Thousand Miles in Search of a Destination p. 326
Manish Sharma
DOI:10.4103/0028-3886.314575  PMID:33904444
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Basal Cisternostomy - A Microsurgical Cerebro Spinal Fluid Let Out Procedure and Treatment Option in the Management of Traumatic Brain Injury. Analysis of 40 Consecutive Head Injury Patients Operated with and without Bone Flap Replacement Following Cisternostomy in a Tertiary Care Centre in India Highly accessed article p. 328
Jutty K B C Parthiban, Shanthanam Sundaramahalingam, J Balaparameswara Rao, Vaishali Pralhad Nannaware, Vishnu Najarubhai Rathwa, Vaibhav Yogesh Nasre, Shantigrama Thirumalachar Prahlad
DOI:10.4103/0028-3886.314535  PMID:33904445
Background: Decompressive craniectomy (DC) is considered the gold standard blanket surgical procedure for all medically intractable cerebral oedema in Traumatic Brain Injury (TBI). It's only proven fact is that it reduces Intra Cerebral Pressure (ICP) by providing space for the oedematous brain. Attempts are being made to find additional or alternative procedures to improve outcomes in TBI. Basal Cisternostomy is one such technique proposed to bring such a change in world literature. Aim: To analyse the validity of Basal Cisternostomy in TBI patients Materials and Methods: A total of 40 patients who underwent Basal Cisternostomy (BC) in TBI admitted in the senior author's unit between January 2016 and April 2019 were analysed retrospectively. All surgeries were performed by single surgeon with microsurgical expertise. Outcome was assessed according to Glasgow outcome scale (GOS). Results were analysed using SPSS software. Results: In severe TBI, Basal Cisternostomy group showed 77.8% favourable outcome while Decompressive Craniectomy in addition to Basal Cisternostomy group showed 72.7% only. While favourable GOS was seen in 82% (33/40), the unfavourable outcome was noticed in 12.5% (5/40) and death in 5% (2/40) in this series. Hydrocephalus was seen in 12.5% (5/40). Patients operated earlier from the time of injury showed better results than those who got operated later irrespective of severity of neurological status. ICU stay and hospital stay duration and its validity could not be assessed. Conclusion: Basal Cisternostomy is an effective procedure in Traumatic Brain Injury patients that not only improves outcome but also reduces the need for Decompressive Craniectomy as a blanket procedure and thus avoiding its associated complications.
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CSF Shift Edema - Role of “Fluid Shift” in Adopting a Microsurgical Technique for Moderate to Severe Head Injuries p. 334
Hira Burhan, Iype Cherian
DOI:10.4103/0028-3886.314534  PMID:33904446
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Predictors of Quality of Life at 3 Months after Treatment for Aneurysmal Subarachnoid Hemorrhage p. 336
Akshay V Kulkarni, Bhagavatula Indira Devi, Subhas K Konar, Dhaval Shukla
DOI:10.4103/0028-3886.314581  PMID:33904447
Background: Patients with aneurysmal subarachnoid hemorrhage (SAH) have a low quality of life (QOL) despite diagnostic and therapeutic advancements. Less than half of the survivors can return to their previous jobs and have difficulty in being a functional part of society. Our study aimed to understand the overall outcome and QOL of these patients and to identify the predictive factors determining the same. Methods: The clinical and radiological data were recorded at presentation, subsequent intervals at the hospital, and during discharge. Patients were interviewed telephonically or in the clinic subsequently at 3 months after treatment with following outcome assessment tools: Modified Rankin Scale (mRS), Barthel Index (BI), QOL after Brain Injury Overall Scale (QOLIBRI-OS), and Short Form 36 (SF 36) QOL scale. Results: Out of the total patients (n = 143), 124 patients survived, of which 106 patients could be interviewed. The mRS, QOLIBRI-OS, BI, and SF36 had a good correlation with each other. Only 4.7% had moderate to severe disability on the mRS scale, and 2.8% had severe disability according to the Barthel index. Nearly one-third of patients had deteriorated QOL. The mental health domain was worst affected. The major determinant of QOL was GCS at presentation (mean P value 0.01), a course in the ward (0.0001), GCS at discharge (0.001). Conclusion: Though fewer of the patients had a severe disability, a majority of them had deterioration in QOL.
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Life after Subarachnoid Hemorrhage: Is Everything All Right? p. 342
Nishant Goyal
DOI:10.4103/0028-3886.314558  PMID:33904448
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Turning a New Chapter in Neurosurgery Outpatient Services: Telemedicine A “Savior” in this Pandemic Highly accessed article p. 344
Amol Raheja, Niveditha Manjunath, Kanwaljeet Garg, Vivek Tandon, Vivek Gupta, Shashwat Mishra, Sameer Ather, Ashish Suri, P Sarat Chandra, Manmohan Singh, Ahamadulla Shariff, Shashank S Kale
DOI:10.4103/0028-3886.314523  PMID:33904449
Background: Teleconsultation services in India, especially in neurosurgery, are relatively new. Despite its large-scale adoption during the COVID-19 pandemic, comprehensive analyses of patients' perspectives and hurdles are lacking. Materials and Methods: We conducted an anonymized telephonic survey of consecutive neurosurgical patients who availed telemedicine services at our institute, using a validated, structured questionnaire. To prevent bias, interviewers were not involved in the study design/analyses. Patients' perception of usefulness and performance of teleconsultation was graded on a 5-point Likert scale. Results: Of the 330 patients who availed teleconsultation services, 231 (70%) completed the survey. Even though 91% of the respondents had access to a smartphone, only 10% received a video-based teleconsult. As per respondents, the challenges included poor network (7%), suboptimal communication/discussion (5.6%), lack of physical examination (6%), and misinterpretation of prescription by pharmacists/patients (6%). The majority of the respondents (58%) either agreed/strongly agreed that teleconsultation helped them tide over the medical exigency during the lockdown; however, the clinical diagnosis did not influence this response (P = 0.21). The vast majority of the respondents felt that teleconsultation is beneficial (97%), as it minimizes their exposure to COVID-19. One-third of the patients preferred this service over physical visits and 60% agreed to its continuation till resumption of routine care. Access to video-teleconsultation was the chief suggestion in 39 of 74 suggestions received. Conclusions: Telemedicine in neurosurgery offers favorable patient satisfaction during this pandemic and may be a satisfactory alternative to physical outpatient services in the future. Video-based teleconsults should be the preferred modality of communication for neurosurgery patients.
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Telemedicine: An Integral Part of Clinical Neurosciences p. 352
Krishnan Ganapathy
DOI:10.4103/0028-3886.314545  PMID:33904450
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Nonconvulsive Status Epilepticus in Metabolic Encephalopathy in Indonesia Referral Hospital p. 354
Fitri Octaviana, Andriani P Bestari, Anastasia M Loho, Luh A Indrawati, Winnugroho Wiratman, Mohammad Kurniawan, Adhrie Sugiarto, Astri Budikayanti
DOI:10.4103/0028-3886.314533  PMID:33904451
Background: Nonconvulsive status epilepticus (NCSE) is often underdiagnosed in patients with metabolic encephalopathy (ME). The diagnosis of ME should be made specifically to recognize the underlying etiology. Delay in seizure identification and making a diagnosis of NCSE contributed to the poor outcome. Objective: This study aimed to find the incidence and outcome of NCSE in patients with ME. Methods and Material: This was an observational prospective cross-sectional study in patients with ME in emergency and critical care units in Cipto Mangunkusumo General Hospital. The diagnosis of NCSE was based on EEG using Salzburg Criteria for Nonconvulsive Status Epilepticus (SCNC). The outcome was assessed within 30 days after the NCSE diagnosis has been made. Results: A total of 50 patients with ME were involved in this study. NCSE was confirmed in 32 subjects (64%). The most common etiology of ME was sepsis (58%). The mortality rate in the NCSE and non-NCSE group was 40.6% vs 44.4%. Multiple aetiologies were risk factors to poor outcome in the NCSE group. Conclusions: The incidence of NCSE among patients with ME at our hospital was high. Despite the anti-epileptic treatment of the NCSE group, the underlying cause of ME is still the main factor that affected the outcome. Therefore, aggressive treatment of anti-epileptic drug (AED) should be very carefully considered knowing the possible side-effect that might worsen the outcome of patients with ME.
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Non-Convulsive Status Epilepticus in Critically Ill Patients p. 360
Manjari Tripathi, Jasmine Parihar
DOI:10.4103/0028-3886.314548  PMID:33904452
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Clinical and Mutation Spectra of Cockayne Syndrome in India p. 362
Dhanya L Narayanan, Moni Tuteja, Adam D McIntyre, Robert A Hegele, Nadege Calmels, Cathy Obringer, Vincent Laugel, Kausik Mandal, Shubha R Phadke
DOI:10.4103/0028-3886.314579  PMID:33904453
Background: Cockayne syndrome is an autosomal recessive disorder caused by biallelic mutations in ERCC6 or ERCC8 genes. Aims: To study the clinical and mutation spectrum of Cockayne syndrome. Setting and Design: Medical Genetics Outpatient Department of Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. This was a prospective study from 2007 to 2015. Materials and Methods: Clinical details were recorded, and sequencing of ERCC6 and ERCC8 were performed. Results and Conclusions: Of the six families, one family had a homozygous mutation in ERCC8 and the other five families had homozygous mutations in ERCC6. Novel variants in ERCC6 were identified in four families. Phenotypic features may vary from severe to mild, and a strong clinical suspicion is needed for diagnosis during infancy or early childhood. Hence, molecular diagnosis is needed for confirmation of diagnosis in a child with a suspicion of Cockayne syndrome. Prenatal diagnosis can be provided only if molecular diagnosis is established in the proband.
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Worldwide Studies on Cockayne Syndrome are Needed p. 367
Vilhelm A Bohr
DOI:10.4103/0028-3886.314546  PMID:33904454
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Utility of Serial Nerve Conduction Studies in the Electrodiagnosis of Guillain–Barre Syndrome p. 369
Arun Mathai Mani, Appaswamy Thirumal Prabhakar, PT Alexander, Aditya Nair, Asish Vijayaraghavan, Atif Shaikh, Rohit Benjamin, Ajith Sivadasan, Vivek Mathew, Sanjith Aaron, Mathew Alexander
DOI:10.4103/0028-3886.314529  PMID:33904455
Background: Guillain–Barre syndrome can be electrophysiologically classified into demyelinating and axonal subtypes and nerve conduction studies remain the mainstay in electrodiagnosis. Accurate electrodiagnosis has both therapeutic and prognostic significance and different criteria sets have been proposed for classification. Objectives: To electrophysiologically classify GBS patients into AIDP and axonal subtypes according to various published criteria (Cornblath, 1990: Hadden, 1998, Rajabally, 2015), investigate if serial NCS changes the classification, and to identify additional parameters which may support the electrodiagnosis. Materials and Methods: In a retrospective study, we included all patients aged 15 to 80 years, admitted with a diagnosis of GBS between August 2015 and July 2017, who had at least two serial NCS. The various published criteria were applied to the two serial NCS and subtype classification along with diagnostic shifts on serial NCS were ascertained. Results: At the first test, the established criteria gave a yield of 45.2% to 71% for AIDP, while 29% to 54.8% of patients were classified as axonal GBS. In the second study, there was a change in electrodiagnosis, ranging from 9.6% to 16.1%. The resolution of reversible conduction failure and misclassification of subtypes were the major reason for diagnostic shifts. Sural sparing pattern, facial nerve dysfunction, abnormal blink reflex, and phrenic nerve dysfunction were more common in AIDP. Conclusions: Serial nerve conduction studies allow an accurate electrodiagnosis of GBS subtypes, which has both therapeutic and prognostic implications. Also, the use of additional parameters such as blink reflex facial and phrenic nerve conduction may supplement routine NCS.
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Sequential Nerve Conduction Studies in Guillain-Barre Syndrome: Is it Worth the Efforts? p. 376
Madhu Nagappa, Arun B Taly
DOI:10.4103/0028-3886.314554  PMID:33904456
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Comparison of the Solitaire and Trevo Stents for Endovascular Treatment of Acute Ischemic Stroke: A Single.Center Experience p. 378
Jin Wook Baek, Young Jin Heo, Sung Tae Kim, Jung Hwa Seo, Hae Woong Jeong, Eung-Gyu Kim
DOI:10.4103/0028-3886.314580  PMID:33904457
Aims: Limited studies have compared the effectiveness of Solitaire and Trevo stentrievers for endovascular thrombectomy to achieve recanalization and improve functional outcomes of patients with acute ischemic stroke. Therefore, we compared the safety and efficacy of the two stents during endovascular thrombectomy for patients with acute ischemic stroke. Materials and Methods: This study included 130 patients who underwent endovascular thrombectomy using either the Trevo (n = 51) or the Solitaire (n = 79) stent for anterior circulation acute ischemic stroke. Recanalization was classified using thrombolysis in cerebral infarction (TICI) grading. Efficacy and safety of the devices during endovascular thrombectomy were analyzed by evaluating the rate of good recanalization after the first pass, clot retrieval rate, final recanalization grade, use of rescue treatment, recanalization time, and hemorrhagic and thromboembolic complications. Results: Overall, good recanalization (TICI grades 2b and 3) was achieved (Solitaire: n = 57, 72.2%; Trevo: n = 46, 90.2%) (P = 0.01). The rate of good recanalization after the first pass and clot retrieval rate were similar between groups; however, the use of rescue treatment was more frequent in the Solitaire group. Recanalization time was shorter in the Trevo group. The good clinical outcome rate was higher in the Trevo group but not statistically significantly. The rates of symptomatic hemorrhage and thromboembolism were not significantly different between groups. Conclusion: The Trevo stent achieved more successful recanalization with less need for rescue treatment and less time for recanalization than the Solitaire stent. There was no statistically significant difference in the clinical outcomes.
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Stentriever Thrombectomy for Acute Ischemic Stroke p. 383
Anil Pandurang Karapurkar, Narayan Dilip Deshmukh, Rakesh K Singh
DOI:10.4103/0028-3886.314555  PMID:33904458
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Recurrent Neurocysticercosis: Not So Rare p. 385
Khush Preet Kaur, Ajay Garg, Leve Joseph Devaranjan Sebastian, Rohit Bhatia, Mamta Bhushan Singh, Achal Srivastava, Manjari Tripathi, MV Padma
DOI:10.4103/0028-3886.314519  PMID:33904459
Background: Solitary cysticercus granuloma (SCG) appearing as a single ring-enhancing lesion (SREL) is the most frequently encountered imaging finding in patients of neurocysticercosis (NCC) in India and during follow-up, most of SCGs resolve with or without calcifications. Recurrent SCG have been rarely reported. Objectives: The aim of our study is to report the incidence of recurrent SCG in a cohort of patients with SCG and postulate the hypothesis. Materials and methods: This retrospective study included 278 patients with SCG meeting the criteria of NCC. Their medical records and imaging studies were analyzed. Results: Out of 278 patients, 119 patients with SCG meeting the criteria of NCC with follow-up imaging were included. 15 (12.61%) had recurrent NCC and 104 (87.4%) patients did not have any recurrence during a median follow-up of 14.23 months (range; 0.24 - 113.3) and 25.26 months (range; 3.09- 98.11) respectively. Out of 15 recurrent NCC cases, ten patients had documented imaging resolution or partial regression of previous lesion followed by occurrence of new SCG in the same location, three patients had change in morphology of lesion from solitary discrete REL to solitary conglomerate REL secondary to development of new cysticercus granuloma adjacent to old lesion patients had recurrent lesions adjacent to previous lesion and two patients had new SCG in different locations following regression of old SCGs. Conclusion: Recurrent SCGs are not uncommon in NCC and recurrence is more likely to occur at the site of initial infection and therefore may be mistaken for persistent infection or other granulomatous lesions.
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Recurrent Solitary Cysticercus Granuloma: Definition is Crucial p. 392
Vedantam Rajshekhar
DOI:10.4103/0028-3886.314532  PMID:33904460
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Role of Double Inversion Recovery Sequence in Neuro-imaging on 3 Tesla MRI p. 394
Shilpa Kulkarni, Makarand M Kulkarni, Aparna Patankar, Apurva Watve
DOI:10.4103/0028-3886.314551  PMID:33904461
Double Inversion Recovery (DIR) is a robust sequence designed to suppress fat and water signals using two 180° inversion pulses to produce prominent gray matter contrast with high spatial resolution. It has proven to be more sensitive in delineating white matter signal abnormalities than conventional MR techniques. In our study, the highest image contrast with lesion load was observed using DIR over FLAIR and T2 weighted imaging. DIR is evidently valuable for the detection of demyelinating lesions observed in multiple sclerosis (MS), malignancies, epileptogenic foci, and cortical anomalies. Hence this pictorial review is intended to assess the diagnostic efficacy of DIR modality in clinical Neuro-imaging.
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Double Inversion Recovery: Another Feather in MRI Cap p. 397
Parveen Gulati
DOI:10.4103/0028-3886.314550  PMID:33904462
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Transpedicular Approach for Corpectomy and Circumferential Arthrodesis in Traumatic Lumbar Vertebral Body Burst Fractures: A Retrospective Analysis of Outcome in 35 Patients p. 399
Mayank Garg, Amandeep Kumar, Pankaj Kumar Singh, Raman Mahalangikar, Guru Dutt Satyarthee, Deepak Agrawal, Deepak Gupta, Hitesh Kumar Gurjar, Shashwat Mishra, Poodipedi S Chandra, Shashank S Kale
DOI:10.4103/0028-3886.314521  PMID:33904463
Background: Traumatic vertebral burst fractures can be surgically approached via different approaches (anterior/posterior, or combined). Transpedicular approach (TA) is a posterior approach that has the advantage of achieving circumferential arthrodesis via single posterior only approach. The purpose of this study was to analyze our experience with TA in management of traumatic lumbar burst fractures (TLBFs). Materials and Methods: All consecutive patients with TLBFs managed with TA over 5 years duration were included in this retrospective study. Correction of kyphotic deformity and change in neurological status were analyzed to assess outcome. Cobb's angle and ASIA grade were used for this purpose. Results: There were 21 males and 14 females. Eight patients had complete (ASIA-A) while 22 had incomplete injury. All patients had a TLICS score >=4. The mean preoperative Cobb's angle was 13.97° that improved to -3.57° postoperatively (mean kyphosis correction-17.54°). None of the patients developed iatrogenic nerve root injury. There was no perioperative mortality. The mean cobb's angle was 1.23° at 39.1 months follow-up. Eight patients developed cage subsidence but none required revision surgery. Postoperatively, 27 (77.1%) patients showed neurological improvement and none deteriorated. The median ASIA score improved from 3 to 5. A fusion rate of 91.4% was observed at last follow-up. Conclusions: The advantages of TA including sense of familiarity with posterior approach amongst spine surgeons, lesser approach-related morbidity, and results comparable to anterior/combined approaches, make TA an attractive option for managing TLBFs. Although technically difficult, it can be successfully used for circumferential arthrodesis in lumbar region without sacrificing nerve roots.
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Is “En Masse” Tumor Resection a Safe Surgical Strategy for Low-Grade Gliomas? Feasibility Report on 74 Patients Treated Over Four Years p. 406
Atul Goel, Abhidha Shah, Ravikiran Vutha, Saswat Dandpat, Akshay Hawaldar
DOI:10.4103/0028-3886.314527  PMID:33904464
Background: Gliomas are “confined” tumors arising from a named white fiber tract and displacing adjoining “normal” white fibers. The surgical strategy of “en masse” resection of gliomas based on this concept is evaluated. Objective: We evaluate the feasibility of the surgical strategy of “en masse” tumor resection for low-grade gliomas arising from the short arcuate fibers. Methods: We retrospectively evaluated our series of 74 patients with low-grade gliomas involving the short arcuate fibers who were operated on between the years January 2016 and June 2019. The tumor resection was done on the premise that gliomas arise from and grew along a specific white fiber tract and the expanding tumor displaced but did not transgress the border formed by adjoining tracts. Although modified as per the situation, an en masse tumor resection strategy was the basis of surgical resection. Intraoperative motor cortical and subcortical mapping was performed in 14 cases. Awake surgery was performed on 11 patients. Results: There were 46 males and 28 females. Total/supratotal tumor resection was achieved in 62 (83.8%) patients. Forty-seven patients had an essentially en masse tumor resection. Seventy-one patients improved in their preoperative complaints. The follow-up ranged from 11 to 56 months. Sixty-two patients who underwent a total or supratotal resection were not given any adjuvant treatment. Twelve patients with subtotal resection were subjected to adjuvant radiotherapy with or without additional chemotherapy. Conclusions: En masse tumor resection of low-grade gliomas is possible and “safe” based on understanding that gliomas are “confined” tumors and have a well-defined plane of surgical dissection.
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Auditory Temporal Ordering in Patients with Medial Temporal Lobe Epilepsy with and without Hippocampal Sclerosis p. 414
Aravind K Rajasekaran, Nagarajarao Shivashankar, Sanjib Sinha, Jitender Saini, Doddaballapura K Subbakrishna, Parthasarathy Satishchandra
DOI:10.4103/0028-3886.314569  PMID:33904465
Context: Temporal lobe epilepsy can affect central auditory processing (CAP) skills. Auditory temporal ordering (ATO) is a CAP skill that can be evaluated using duration pattern test (DPT). Aim: The aim is to evaluate ATO in patients with medial temporal lobe epilepsy (MTLE) with hippocampal sclerosis (MTLE + HS) and without hippocampal sclerosis (MTLE-HS) and in their subgroups. Settings and Design: It was a prospective cross-sectional behavioral observational study conducted in a tertiary neuropsychiatric hospital. Subjects and Methods: The subjects were patients with refractory MTLE (N = 100), comprising 50 “MTLE + HS” patients and 50 “MTLE-HS”. Age-range matched normal healthy subjects (n = 50) formed the control group. Both groups were administered duration pattern test (DPT). Statistical Analysis Used: Analysis of variance (ANOVA) with post hoc analysis, Dunnett's two-sided and Bonferroni, paired sample t-test, Pearson's correlation, and independent t-test. Results: The clinical groups performed significantly poorer than the control group, and however, did not differ significantly between them. The age at onset and the duration of the seizures did not have significant relation with the test measures. Conclusions: Patients with “MTLE + HS” as well as those with “MTLE-HS” and their respective subgroups revealed abnormal ATO indicating CAP dysfunction.
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Determinants of Suboptimal Outcome Following Thymectomy in Myasthenia Gravis p. 419
AS Shreedhara, Sruthi S Nair, Madathipat Unnikrishnan, S Sandhyamani, PS Sarma, Muralidharan Nair, C Sarada
DOI:10.4103/0028-3886.314565  PMID:33904466
Background: Response to thymectomy in myasthenia gravis (MG) is influenced by various patient-, disease-, and therapy-related factors. Methods: Retrospective analysis of 128 patients with MG who underwent maximal thymectomy over 15 years was done to identify the determinants of suboptimal clinical outcome. Results: Among the 128 patients, 62 (48.4%) were females with a mean age of 38.97 (12.29) years. Thymomatous MG occurred in 66 (51.6%). Overall improvement from preoperative status was noted in 88 (68.8%) patients after mean follow-up of 51.68 (33.21) months. The presence of thymoma was the major predictor of suboptimal clinical outcome (P = 0.001), whereas age, gender, preoperative disease severity, and seropositive status did not attain significance. Patients with better outcome had received higher steroid dose preoperatively (P = 0.035). Conclusions: Suboptimal response after thymectomy occurred in one-third of MG patients, more commonly with thymomatous MG. Relationship of preoperative steroid therapy to remission merits evaluation.
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Effects of Tempol on Epileptic Activity in Picrotoxin-Induced Epilepsy in Rats p. 426
Neslihan Pinar
DOI:10.4103/0028-3886.314542  PMID:33904467
Introduction: Epilepsy is a common neurological disease, although its etiology and pathophysiology are not yet fully understood. Oxidative stress plays a key role in the pathogenesis of many neurological diseases, including epilepsy, and there have been many studies reporting that antiepileptic medicines with neuroprotective and antioxidant activity inhibit free oxygen radicals. This study evaluates the effects of tempol on epileptic activity through behavioral parameters in acute picrotoxin (Ptx) models. Materials and Methods: This experimental study was conducted on 42 adult male Wistar Albino rats weighing 450–500 g. Ptx (2.5 mg/kg) was injected i.p. as a single dose and observed for one hour to establish the acute Ptx model. Following injection, the animals were observed for 30 min in glass observation cages measuring 35 cm x 35 cm x 35 cm. Results: In picrotoxin-induced epilepsy, the total number of seizures and the total duration of seizures were decreased significantly with Ptx + tempol 100 mg/kg and Ptx + Tempol 150 mg/kg. The seizure phases were reduced significantly by Ptx + tempol 150 mg/kg (P < 0.05). Conclusion: Tempol 100 mg/kg and tempol 150 mg/kg are found to be effective in epilepsy models caused by Ptx, with tempol 150 mg/kg found especially to be more effective.
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Predicting Long-Term Outcome of Patients of Early Parkinsonism with Acute Levodopa Challenge Test p. 430
Mrinal Acharya, Subhadeep Banerjee, Apratim Chatterjee, Adreesh Mukherjee, Samar Biswas, Goutam Gangopadhyay, Atanu Biswas
DOI:10.4103/0028-3886.314539  PMID:33904468
Objectives: The aim of this study was to evaluate the sensitivity and specificity of various outcomes of acute levodopa challenge test (ALCT) namely improvement of motor function, development of dyskinesia and intolerance; to predict the diagnosis of idiopathic Parkinson's disease (IPD) or Parkinson-plus syndrome; to predict levodopa responsiveness and levodopa-induced dyskinesia (LID) during long-term therapy. Methods: ALCT was performed on 89 patients with parkinsonism of <2 years and were followed up for 18 months. Improvement of UPDRSm by ≥30% was considered positive. Results: The test was positive in 37 (43.5%) and negative in 48 (56.5%) of 85 patients completing it. Of the 75 patients completing 18 months' follow-up 34 (45.3%) were diagnosed as IPD. A positive ALCT predicted a clinical diagnosis of IPD with sensitivity and specificity of 97.4% and 70.7% respectively. The predictive value of ALCT for long-term levodopa responsiveness was less than predicting a diagnosis of IPD. While appearance of dyskinesia during ALCT had a low predictive value for future LID (sensitivity 14.3%), it had high predictive value for a diagnosis of multisystem atrophy (MSA) (91% specificity and 37.5% sensitivity). The appearance of symptoms of levodopa intolerance (SLI) during ALCT could predict a clinical diagnosis of MSA with high specificity (95.5%) and moderate sensitivity (50%). Conclusion: Levodopa responsiveness during ALCT was useful in predicting a diagnosis of IPD but not long-term response to levodopa. The development of dyskinesia during ALCT could not correctly predict LID, but could predict a diagnosis of MSA. The appearance of SLI during ALCT could also predict MSA correctly.
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Shared Decision-Making in the Management of Women with Epilepsy p. 435
Manjari Tripathi, Jasmine Parihar
DOI:10.4103/0028-3886.314547  PMID:33904469
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Drug-Induced Parkinsonism p. 437
Kanwaljeet Garg, Roopa Rajan, Manmohan Singh
DOI:10.4103/0028-3886.314567  PMID:33904470
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Proinflammatory Cytokines in Acute Ischemic Stroke: Where are we Now? p. 439
Adria Arboix, María-José Sánchez-López
DOI:10.4103/0028-3886.314537  PMID:33904471
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Orbital Rim Sparing Single-piece Fronto-orbital Keyhole Craniotomy Through Eyebrow Incision: A Technical Report and Comparative Review p. 441
Sivashanmugam Dhandapani, Lomesh S Wankhede
DOI:10.4103/0028-3886.314520  PMID:33904472
Background: The classical eyebrow supraorbital keyhole craniotomy has limited working volume due to the thick incurving of the frontal bone necessitating generous drilling of the frontal base. However, the basal variant with sectioning of the orbital rim results in increased periorbital edema. Objective: We describe a novel orbital rim sparing single-piece fronto-orbital keyhole approach, probably the first such report with a comparative review of relevant literature. Methods: Following eyebrow incision, bidirectional drilling with a ball tip behind the fronto-zygomatic suture exposes the periorbita and frontal dura, with orbital roof in-between. The craniotomy is fashioned with an angled fronto-orbital cut parallel to and sparing the orbital rim with dura-guard over the periorbita, a frontal cut over the dura, and an optional cut along the lateral orbital roof from within the burr hole. A comparative review of this technique with traditional methods is also carried out. Results: Compared to the classical supraorbital keyhole, this minimally invasive approach yields a wider basal exposure with greater working volume for intracranial and orbital lesions. Compared to the basal variant of keyhole fronto-orbital approach, this technique results in the least disturbance to periorbita's attachment with the orbital margin, maintenance of orbital contour, better cosmesis with use of simple tools and self-fitting flap. Conclusion: The orbital rim sparing single-piece fronto-orbital keyhole craniotomy is an easy and novel minimally invasive approach with greater working volume without the disadvantages of sectioning the orbital rim.
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Robot-guided Ventriculoperitoneal Shunt in Slit-like Ventricles p. 446
Ramesh S Doddamani, Rajesh Meena, Dattaraj Sawarkar, Pankaj Singh, Deepak Agrawal, Manmohan Singh, Poodipedi S Chandra
DOI:10.4103/0028-3886.314585  PMID:33904473
Background: Ventriculoperitoneal shunt (VPS) is the most common procedure used in the management of hydrocephalus regardless of the etiology. The standard free-hand technique is used for the placement of VPS in patients with enlarged ventricles. In patients with very small ventricles, CSF access through ventriculostomy becomes challenging and free-hand technique may be associated with high failure rates. In these situations, stereotactic-guided VPS becomes very useful. Objective: To validate and describe the technique of robotic-guided VPS in cases with very small ventricles. Methods: Three patients underwent VPS with robotic guidance between 2016 and 2019. One patient with a diagnosis of occipital meningocele, who later developed recalcitrant CSF leak from the operative site, and two other patients were diagnosed with idiopathic intracranial hypertension (IIH). Plain CT brain with 1-mm slice thickness acquired prior to the surgery was uploaded into the ROSA machine (Zimmer Biomet Warsaw, Indiana). The trajectory for the VPS is created on the robotic software presurgery. The patient is placed in the supine position with head turned to the side contralateral to VPS insertion and fixed with Mayfield clamp. Registration of the patient is done with the robot. The placement of the VPS is commenced with the robotic arm in the predetermined trajectory. Results: Ventricle was hit in a single attempt in all the cases. CSF leak stopped in the case with meningocele; headache, and visual acuity improved in both the cases of IIH. Conclusion: Robotic-guidance provides a safe and accurate method of VPS placement even in the presence of slit-like ventricles.
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Primary Angiitis of Central Nervous System-Tumor-Like Mass Lesions: Report of Six Biopsy Confirmed Cases p. 451
Jagarlapudi M K Murthy, Sundaram Challa, Subhendu Parida, Tenneti V R K Murthy, Syed Ameer Basha Paspala
DOI:10.4103/0028-3886.314536  PMID:33904474
Tumor-like mass lesion is a rare subtype of primary angiitis of the central nervous system (ML-PACNS). This report describes six patients of histologically verified ML-PACNS. The mean age was 44.5 years (range 25–68) and four were males. Presenting symptoms headache (5), focal neurologic deficits (5), and seizures (4). On magnetic resonance imaging (MRI) the lesion was unifocal in two and multifocal in four patients. Consistent radiological findings were mass lesions with heterointense internal morphology with areas of diffusion restriction (DWI), and variable post-contrast enhancement. Pathologically vasculitis was classified as: Granulomatous in one, necrotizing in two and lymphocytic in three. There were two deaths. In conclusion patients with ML-PACNS are likely to be younger and more likely to present with seizures. MRI lesions with hetrointense internal morphology with areas of DWI was a consistent finding and may be a clue for the diagnosis of ML-PACNS.
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Interleaved Stimulation for Freezing of Gait in Advanced Parkinson's Disease p. 457
Syed M Zafar, Roopa Rajan, Syam Krishnan, Krishnakumar Kesavapisharady, Asha Kishore
DOI:10.4103/0028-3886.314570  PMID:33904475
Background: Freezing of gait (FOG) is a disabling and refractory symptom of advanced Parkinson's disease (PD). Interleaved stimulation (ILS) is a novel paradigm which may benefit axial symptoms of PD. Objectives: To assess the effect of ILS on FOG in patients unresponsive to conventional subthalamic nucleus (STN) stimulation. Methods: 19 PD patients receiving subthalamic stimulation and experiencing FOG at both conventional (130–150Hz) and low frequency (60Hz) stimulation were given ILS.The primary outcome measure was the UPDRS part III gait score (item 29) at 3 months after ILS. A subset of patients was tested with the stand–walk–sit (SWS) test, 30 min after ILS. Results: The mean UPDRS part III gait score (baseline: 1.8 ± 0.6) improved at 30 min (1.1 ± 0.8, P = 0.017) and remained improved at 3 months (1.2 ± 0.8, P = 0.048). FOG episodes reduced during SWS test (P = 0.041). Conclusions: ILS of STN through two adjacent contacts provided significant short-term beneficial effects on FOG.
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Mitochondrial DNA Haplogroups and Three Independent Polymorphisms have no Association with the Risk of Parkinson's Disease in East Indian Population p. 461
Tania Saha, Somrita Roy, Rajashree Chakraborty, Arindam Biswas, Shyamal K Das, Kunal Ray, Jharna Ray, Mainak Sengupta
DOI:10.4103/0028-3886.314553  PMID:33904476
Background: Parkinson's disease (PD) is a multifaceted illness affecting ~ 0.3% of the world population. The genetic complexity of PD has not been, fully elucidated. Several studies suggest that mitochondrial DNA variants are associated with PD. Objective: Here, we have explored the possibility of genetic association between mitochondrial haplogroups as well as three independent SNPs with PD in a representative east Indian population. Methods and Material: The Asian mtDNA haplogroups: M, N, R, B, D, M7, and 3 other SNPs: 4336 T/C, 9055 G/A, 13708 G/A were genotyped in 100 sporadic PD patients and 100 matched controls via conventional PCR-RFLP-sequencing approach. Results: The distribution of mtDNA haplogroups, as well as 3 single polymorphisms, did not show any significant differences (P > 0.05) between patients and controls. Conclusion: This is the first of its kind of study from India that suggests no association of selected mitochondrial DNA variations with PD.
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Acute Leucoencephalopathy with Restricted Diffusion in Children – A case series p. 466
Mahesh Kamate, Mayank Detroja, Virupaxi Hattiholi
DOI:10.4103/0028-3886.314577  PMID:33904477
Objective: To study the clinico-radiological profile of children with acute leukoencephalopathy with restricted diffusion. Methods: A retrospective chart review of children with acute leukoencephalopathy with restricted diffusion was done from July 2015 to July 2018. The clinical details, neuroimaging findings, sequelae, and the final outcome on modified Rankin Score were analyzed. Results: Sixteen children with a mean age of 4.4 years were diagnosed with acute leukoencephalopathy with restricted diffusion. All, except one, had fever, seizure, and altered sensorium. The median duration of hospital stay was 3 weeks. Only one out of 16, had biphasic clinical picture that is characteristic of acute encephalopathy with biphasic seizures and restricted diffusion. Magnetic resonance imaging showed restriction diffusion in all. While it was symmetric in 13 children, in 3 children it was asymmetric, and in 2 children there was patchy involvement. Seven children (43.7%) had post-encephalopathic epilepsy. While complete neurological recovery was seen in 2 children, behavioral problems like hyperactivity in 10 (62.5%), speech problems in 8 (50%), and cognitive delay in 3 (18.8%) children were noted. Conclusion: Acute leukoencephalopathy with restricted diffusion is emerging as an important cause of acute encephalopathy in children with a protracted course and long-term sequelae such as cognitive impairment and refractory postencephalopathic epilepsy.
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CASE REPORTS Top

Management Dilemma in A Rare Case of Bilateral Temporo-Insular Glioma p. 470
Rajesh Meena, Ramesh S Doddamani, Harshad Chipde, Deepak Agrawal, Swati Mahajan, PS Chandra
DOI:10.4103/0028-3886.314559  PMID:33904478
Multicentric gliomas are uncommon pathological entities, although well described in the literature. The aim of this study was to highlight the management issues in a rare case of multicentric glioma occurring in a bilateral temporo-insular region. A 35-year-old farmer with no comorbid illness presented with a history of progressively increasing holocranial headaches, intermittent episodes of vomiting, and memory disturbances from the last 3 months. Radiological findings were suggestive of multicentric glioma involving bilateral temporo-insular regions. Patient underwent tumor decompression first on the left side followed by the right side. Postoperative course was uneventful. Management of multicentric gliomas is challenging.
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A Case of CNS Actinomycosis: Rarer than Rare! p. 475
Harshad S Limaye, Anupa R A Hinduja, Mitusha Verma, Pradyumna J Oak
DOI:10.4103/0028-3886.314572  PMID:33904479
We report a case of cerebral actinomycosis in a 62-year-old male who presented with right-sided weakness and focal convulsions. MRI scan showed a solid intra axial space occupying lesion in the left frontal lobe. Left parietal craniotomy with intra-operative USG guided aspiration and excision of the mass (containing necrotic material) was done. Actinomyces israelii was isolated from the aspirated material. Patient received ceftriaxone and clindamycin for 12 weeks. Physiotherapy and anti-epileptic drugs were continued. On subsequent follow-up visits, his power improved to 5/5 in lower limb, 4/5 in proximal upper limb, 2/5 in distal upper limb. Actinomycosis can cause diverse clinical manifestations, and therefore clinical suspicion is key to diagnosis. Early diagnosis and treatment can lead to good treatment outcomes.
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Isolated Cervical Pain Revealing a Common Carotid Artery Dissection in a Child Following a Minor Trauma: A First Pediatric Case Report and a Review of the Literature p. 478
Mariem Messelmani, Manel Akkari, Wala Souissi, Ridha Mrissa
DOI:10.4103/0028-3886.314524  PMID:33904480
Background: Cervical artery dissections are not exceptional in the pediatric population. Typically, it affects the internal carotid artery or the vertebral artery. To our knowledge, this is the first case of common carotid artery (CCA) dissection in a child. Case: We present a case of a 7-year-old-boy admitted to our neurology department complaining of cervical pain after a minor neck trauma. The neurological examination was normal. The ultrasound showed a mural hematoma with an intimal flap. The magnetic resonance angiography revealed an irregular segment of the left CCA just before its bifurcation. The diagnosis of an acute dissection on the left CCA was confirmed and antiplatelet therapy was started. Conclusion: The diagnosis of cervical artery dissections remains a challenge because of its variable clinical presentation. It should be suspected in the context of neck trauma and treatment should be initiated rapidly to reduce the risk of ischemic stroke.
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Neurological Melioidosis Presenting as Rhombencephalitis, Optic Neuritis, and Scalp Abscess with Meningitis: A Case Series from Southern India p. 480
Aparajita Chatterjee, Kavitha Saravu, Chiranjay Mukhopadhyay, Vijay Chandran
DOI:10.4103/0028-3886.314590  PMID:33904481
Melioidosis is an under recognized infectious disease which may rarely present with neurological involvement. Neurological melioidosis has protean manifestations, and in this case series we present 3 patients diagnosed from a single center in southern India. The clinical presentation of the patients we describe includes rhomb-encephalitis, scalp infection with subdural and meningeal involvement, and optic neuritis associated with pulmonary melioidosis. We discuss the possible mechanism of involvement of the nervous system, and the recommended treatment. Diagnosis of melioidosis requires a high index of suspicion and should be considered in endemic areas. Through this series we hope to improve the awareness of this infection and its neurological presentation.
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A Case of Possible IgG4-Related Disease with Bilateral Optic Neuropathy and Bilateral Hippocampal Bleed p. 484
Sujana Gogineni, Anish Mehta, Arjun Gaurang Shah, Selva Kumar, HH Nagappa, R Pradeep, Mahendra Javali, Puroshottam Acharya, Rangasetty Srinivasa
DOI:10.4103/0028-3886.314517  PMID:33904482
IgG4-related disease (IgG4-RD) is a multisystem inflammatory disorder. The diagnosis requires consideration of clinical, radiographic, serological, and pathological evidence. Neurological involvement by IgG4-RD is relatively uncommon and is being increasingly recognized and reported with hypertrophic pachymeningitis and hypophysitis as the most frequent manifestations. IgG4-related involvement of brain parenchyma is rare, but isolated case reports exist. Here, we report a case of a young boy who presented to us with bilateral optic neuropathy and bilateral hippocampal bleed-related neurological involvement in a possible IgG4-RD, a rare entity.
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Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Cervical and Thoracic Spine Surgeries — A Case Series p. 487
Amit Goyal, Pramod Kalgudi, Kamath Sriganesh
DOI:10.4103/0028-3886.314568  PMID:33904483
Erector spinae plane (ESP) block is a recently introduced regional technique for pain management. However, its usefulness for perioperative analgesia in cervical and thoracic spine surgeries is underutilized. In this case series, we reviewed the case records of seven patients who received ultrasound-guided ESP block for perioperative analgesia for cervical and thoracic spine surgeries during a two-month period. We evaluated the performance of the ESP block with regards to intraoperative nociception and hemodynamics, postoperative pain, and need of rescue analgesia in these patients. The median age of our patients was 28 years (range 5–74 years) and the duration of surgery was 300 minutes (range 240–540 minutes). The surgical pleth index, a marker of intraoperative nociception, was below the threshold of 50 at most time-points during the surgery. Similarly, intraoperative hemodynamic parameters (HR and BP) were stable throughout the surgery. Postoperative pain control was good during the initial 48 after surgery with median NRS score of 2 at rest and 4 with movement. The ESP block results in good intraoperative and postoperative analgesia and also provides hemodynamic stability and opioid-sparing effect for cervical and thoracic spine surgeries.
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Acute Necrotizing Encephalopathy as a Complication of Chikungunya Infection p. 490
VV Holla, Abhishek B Gohel, N Kartik, M Netravathi
DOI:10.4103/0028-3886.314525  PMID:33904484
Background: Acute necrotizing encephalopathy (ANE) is a rapidly progressive encephalopathy seen commonly in children triggered by various prodromal viral infections, most common being influenza virus and Human herpes virus-6. Objective: We report two rare cases of ANE preceded by Chikungunya infection. Cases: A 13-year old girl presented with a three-day history of headache, fever, seizures, and altered sensorium. Another 42-year old man presented with two days history of fever and altered sensorium. Both were suspected to have viral encephalitis. Evaluation revealed serum positivity for Chikungunya virus. In both cases, diagnosis was clinched by characteristic bilateral symmetrical thalamic lesions with central necrosis and hemorrhage along with lesions in cerebral white matter, brainstem, and cerebellum. Conclusions: ANE is reported to have high morbidity and mortality. To the best of our knowledge, this is the first report of ANE post-Chikungunya infection. Apart from being rare etiologically, the patients had excellent response to steroids.
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An Unusual Case of Muscle Twitching: Its LGI1 p. 493
Laxmikant Ramkumarsingh Tomar, Dhrumil Jatinbhai Shah, Rajeev Ranjan, Anshu Rohatgi, CS Agrawal
DOI:10.4103/0028-3886.314549  PMID:33904485
A 50-year-old male, presented with a two-months history of ascending paresthesias, with continuous twitchings over the body, associated with insomnia. His electromyography (EMG) revealed neuromyotonia and was diagnosed as a case of peripheral nerve hyperexcitability (PNH) syndrome due to Leucin-rich glioma-inactivated 1 (LGI1) antibody. He showed significant improvement with intravenous immunoglobulin and carbamazepine.
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Acute Acalculous Cholecystitis in a Multiple Sclerosis Patient Treated with Natalizumab p. 495
Alvaro Lambea-Gil, Luis Fumanal-Idocin, Berta Sebastián-Torres, Ignacio Saldaña-Inda, Patxi Huici-Polo, Raquel Alarcia-José-Ramon- Ramon Ara-Callizo
DOI:10.4103/0028-3886.314544  PMID:33904486
Natalizumab is a disease-modifying drug that has proved greatly effective and well-tolerated in highly-active Multiple Sclerosis (MS). However, it may increase the risk for opportunistic infections, such as viral ones. We describe a 37-year-old woman treated with Natalizumab for Relapsing-Remitting Multiple Sclerosis (RR-MS) who presented to our clinic with malaise, arthromyalgias, rash, and fever. She later developed diarrhea and severe abdominal pain. A diagnosis of parvovirus B19 (B19V) infection and acute acalculous cholecystitis (AAC) was eventually made. To our knowledge, this is the first reported case of AAC possibly related to Natalizumab therapy and B19V infection.
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Primary Central Nervous System Lymphomatoid Granulomatosis Presenting as Diffuse Corpus Callosum Lesions p. 497
Yuanyuan Xiang, Jifeng Li, Qinjian Sun, Xiaohui Liu
DOI:10.4103/0028-3886.314578  PMID:33904487
Lymphomatoid granulomatosis (LYG) is a rare lymphoproliferative disease characterized by angiocentric and angiodestructive infiltrate. It primarily affects the lung and sometimes may also affect the central nervous system (CNS), skin, kidney, liver, etc., but the involvement of lymph nodes and/or bone marrow is extremely rare, and if present, other diagnoses are usually considered. Isolated CNS involvement is very rare, and its pathogenesis and biological behavior have been controversially discussed. Here, we report a 46-year-old man with diffuse and symmetrical corpus callosum involvement. The histopathological findings were in keeping with LYG. Since there was no evidence of involvement of other organs, he was diagnosed with primary CNS-LYG. He responded well to steroids and his symptoms improved significantly. We also conduct an English literature review to provide clues for the diagnosis and treatment of this disease.
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LETTERS TO EDITOR Top

Disseminated Craniospinal Myxopapillary Ependymoma Treated with Biopsy and Adjuvant Radiation Therapy: A Case Report and Review of Literature p. 500
Ajit Mishra, Nishanth Sadashiva, Uday Krishna, Subhas Konar, BN Nandeesh, Vani Santosh, Aravind Gowda, Bhagavatula Indira Devi
DOI:10.4103/0028-3886.314566  PMID:33904488
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Postgraduate Training in Neurosurgery in India: The Problems and the Possible Remedies p. 505
Vengalathur G Ramesh
DOI:10.4103/0028-3886.314526  PMID:33904489
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What's with Neurosurgery, Surgery and Shalychikitsa p. 507
Himanshu Raval
DOI:10.4103/0028-3886.314540  PMID:33904490
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Recurrence of Sporadic Intracranial Cerebellar Hemangioblastoma: Case Report and Literature Review p. 508
Madhavi Ashok Jejurkar, Shrenil Gulab Lagad, Rakesh Ranjan
DOI:10.4103/0028-3886.314560  PMID:33904491
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Management of Radio Surgical Failures: New Insights and Future Prospects p. 511
Manjul Tripathi, Aman Batish, Sandeep Mohindra, Amit Joshi
DOI:10.4103/0028-3886.314562  PMID:33904492
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COVID-19 Pandemic: A Wake-Up Call for Indian Medical Research p. 513
Siddharth Agrawal, Vivek Tandon
DOI:10.4103/0028-3886.314586  PMID:33904493
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Paroxysmal Dysarthria Ataxia–Tremor–Blepharospasm Syndrome in Bickerstaff Brainstem Encephalitis: A Variant of Paroxysmal Dysarthria Ataxia Syndrome p. 515
Enrico Ferrante, Michele Trimboli
DOI:10.4103/0028-3886.314518  PMID:33904494
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Chronic Cervical Dystonia Complicating Cervical Myelopathy—A Therapeutic Challenge Managed by Botulinum Toxin and Surgical Intervention p. 517
SP Chaithra, Vikram Holla, Akshay Kulkarni, Pramod K Pal, Ravi Yadav, Nupur Pruthi
DOI:10.4103/0028-3886.314583  PMID:33904495
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Early Loss of Bone Mineral Density in Parkinson's Disease Patients p. 520
Jasmine Parihar, Vinay Goyal
DOI:10.4103/0028-3886.314582  PMID:33904496
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Idiopathic Spinal Accessory Neuropathy: A Case Report p. 522
Dimitrios Tsiptsios, Christoph Mueller, Konstantinos Tsamakis
DOI:10.4103/0028-3886.314589  PMID:33904497
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Nutritional Management of Diencephalic Syndrome: A Case Series p. 524
Ekta Chheda, Samina Vora, Maya Prasad
DOI:10.4103/0028-3886.314587  PMID:33904498
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Iatrogenic Lagophthalmos or Lid Lag. An Uncommon Occurrence Following Scalp Block p. 526
Manish Kumar Singh, Rudrashish Haldar, Ashish K Kannaujia, Kuntal K Das
DOI:10.4103/0028-3886.314563  PMID:33904499
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Myasthenia Gravis with Thymoma and a Rare Serological Profile—Report of a Case and Review of Literature p. 528
Deepti Narasimhaiah, Sapna E Sreedharan, A Anoop, Neelima R Radhakrishnan, Rajalakshmi Poyuran
DOI:10.4103/0028-3886.314552  PMID:33904500
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NEUROIMAGES Top

Intramuscular Nodular Fasciitis Mimicking a Peripheral Nerve Sheath Tumour p. 530
Roberto S Martins, Mario G Siqueira
DOI:10.4103/0028-3886.314571  PMID:33904501
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Giant Pituitary Adenoma Causing a Split in Optic Chiasm p. 532
Hitesh I S Rai, Manmohan Singh, Pankaj K Singh, Aruna Nambirajan, Amit Sharma, Ankit Jain
DOI:10.4103/0028-3886.314530  PMID:33904502
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Thoracic Chondrosarcoma with a Polka-dot Appearance p. 534
Manish K Kasliwal, Aparna Harbhajanka, Marta Couce
DOI:10.4103/0028-3886.314573  PMID:33904503
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Brainstem Predominant Posterior Reversible Encephalopathy Syndrome p. 536
Guillaume Lamotte, Abhishek Lenka
DOI:10.4103/0028-3886.314564  PMID:33904504
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The Devastating Starfield Pattern of Cerebral Fat Embolism p. 538
Enambir S Josan, Gabriel A Zaietta, Girendra V Hoskere
DOI:10.4103/0028-3886.314561  PMID:33904505
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BOOK REVIEW Top

SGPGI Neurosurgery: The Operative Atlas of Neurosurgery. A Compendium of 120 Neuro-Oncological, Case-Based, Surgical Approaches p. 540
Sunil K Pandya
DOI:10.4103/0028-3886.314557  
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